questions 9

Diabetic Ketoacidosis (DKA)

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Topic updated on 07/08/17 11:30am

Snap Shot
  •  A 12 year old boy, previously healthy, is admitted to the hospiral after 2 days of polyuria, polyphagia, nausea, vomting and abdominal pain. Temp is 37, BP 103/63, HR 112, RR 30. Physical exam shows a lethargic boy.  Glucose is 534, Potasium is 5.9; WBC 16,000, pH is 7.13, PCO2 is 20 mmHg, PO2 is 90 mmHg.
Introduction
  • Results from
    • absolute deficiency in insulin
    • surge in counterregulatory homones (glucagon, growth hormone, catecholamine)
    • results in hyperglycemia and ketonemia
  • Most common in type I diabetes
  • Precipitated by
    • infections
    • MI
    • drugs (steroids, thiazide diuretics)
    • noncompliance
    • pancreatitis
Presentation
  • Symptoms 
    • vomiting
    • abdominal pain
    • Kussmaul Respiration (increased tidal volume)  
    • fruity, acetone odor
    • severely dehydrated
    • cerebral edema
      • associated with high mortality in pediatric patients
Evaluation
  • Diagnostic criteria
    • blood glucose levels > 250 mg/dL
    • Arterial pH < 7.3
    • Serum bicarbonate < 15mEq/L
    • Moderate ketonuria and ketonemia
  • Labs show:
    • increased anion gap metabolic acidosis
Treatment
  • Fluids
  • Insulin with glucose 
    • give insulin until ketones are gone, even after glucose normalizes or is below normal
  • Replace potasium for hypokalemia 
    • caused by too much potassium being secreted in the urine as a result of the glucosuria
    • labs may show pseudo-hyperkalemia  
      • due to transcellular shift of potassium out of the cells to balance the H being transfered into the cells 
    • give in the form of potassium phosphate rather than potasium chloride
  • Aggresive electrolyte replacement
    • give phosphate supplementation to prevent respiratory paralysis
  • If mental status changes (headache, obtundation, coma) occur during treatment
    • likely due to cerebral edema
    • give mannitol
  • Follow anion gap to monitor improvement


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Qbank (2 Questions)

TAG
(M2.EC.2) A 19-year-old male presents to the emergency room with altered mental status. History is remarkable for increased urination over the past few months. On physical examination, he is a thin, young man with labored breathing, abdominal tenderness, and mild flank pain. Temperature is 37.0 degrees Celsius. An arterial blood gas shows serum pH 7.05, pCO2 17, HCO3 6, pO2 90. This patient is most likely suffering from which of the following? Topic Review Topic

1. Alcohol poisoning
2. Hormone deficiency
3. Pyelonephritis
4. Aortic aneurysm
5. Ruptured appendix

PREFERRED RESPONSE ▶
TAG
(M2.EC.99) An 18-year-old male with a past medical history of type I diabetes presents to the emergency room with polyuria, polydipsia, and dehydration. Vital signs reveal tachycardia and hypotension. Physical exam is significant for dry mucous membranes and decreased skin turgor. In the waiting room he begins vomiting and complains of intense abdominal pain. You observe him taking rapid, deep breaths, and over the course of his brief stay, getting more somnolent. Which of the following abnormalities would be expected in this patient? Topic Review Topic

1. Hypernatremia
2. Decreased total body potassium
3. Hypoglycemia
4. Absence of urinary beta-OH-butyrate
5. Non anion-gap metabolic acidosis

PREFERRED RESPONSE ▶
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